INTRODUCTION
A concise list of medications targeted at common symptoms is a useful tool for health care providers who seek to alleviate a broad range of patient concerns. It allows individuals to make faster decisions about pharmacologic treatment for common disease symptoms that may be outside of their realm of expertise. It provides autonomy for nurses, physician assistants, and nurse practitioners to administer agreed upon amounts of known medications under a physician's supervision. If regularly updated and reviewed, it can provide physicians from different disciplines an opportunity for dialogue and education about common symptoms and their first line treatments.
The University of California, Davis Medical Center (hereinafter UCDMC) Hospice Program is one such program that benefits enormously from the use of such formularies. The Hospice Program works to palliate the symptoms of over 70 patients with terminal illnesses each month. Twelve to 15 hospice nurses administer care through home visits and phone calls. They are supervised by a physician as needed by phone and meet weekly with the medical director. The program utilizes standardized medication formularies targeted at common end-of-life symptoms such as pain, delirium, and depression, which empowers nurses to make therapeutic decisions at the point of care. The resultant nurse autonomy allows for more rapid alleviation of patient discomfort and increases direct patient contact time.
Many hospice patients encounter a diverse symptom complex including pain, constipation, nausea, cough, anorexia, and dyspnea. Psychiatric symptoms are also prevalent in terminal illness, including anxiety, delirium, terminal agitation, insomnia, and fatigue (Portenoy et al., Reference Portenoy, Thaler and Kornblith1994; Vogl et al., Reference Vogl, Rosenfeld and Breitbart1999; Akechi et al., Reference Akechi, Okuyama and Sugawara2004). With a finite number of medications presented in suggested dosing regimens, nurses are able to relieve patients' symptoms during a home visit when the clinical concern arises by referencing a simple chart. This provides a point of care tool for nurses so that they may quickly assess the patients' concerns and formulate recommendations to present to the supervising physician for review. This efficiency translates into more time for patient contact and care.
Although a hospice program is especially well suited for such a formulary due to the frequent repetition of specific symptom sets, the model can easily be applied to other disciplines where a particular patient population is likely to experience a specific subset of concerns. Examples include internal medicine and surgical patients experiencing depression and delirium during long hospital stays or psychiatric patients experiencing diabetes and hypercholesterolemia secondary to antipsychotic use.
However, busy treatment teams become accustomed to the status quo, and formulary renovation often falls by the wayside, with newer medications and emerging evidence eluding incorporation. Here we present a methodology for an interdisciplinary renovation of a hospice formulary, the before and after products, and the outreach and education program designed to facilitate its implementation. Although our project focused on psychotropic medications in a hospice formulary, this model can be easily applied to other formularies and other specialties.
The work is not done once the formulary has been submitted and implemented in the field. The constantly emerging new evidence and new medications mandates a level of dynamism in formularies that may be difficult to maintain. Specialty consultation can facilitate integration of new information and summarization of new findings relevant to the formulary. Such coordination of communication is difficult to orchestrate on a busy medical service, but it is integral to maintaining the efficacy of the formulary as well as providing an opportunity for physicians from different services to collaborate. Quality hospice care that incorporates treatments for a diverse symptom set during a sensitive time mandates ongoing multidisciplinary contributions.
METHOD
The UCDMC hospice formulary had not been revised since 2001 and had never been reviewed in conjunction with a psychiatrist. Numerous areas of potential improvement were identified, specifically in the section devoted to psychiatric symptoms in hospice patients. Depression, agitation, and insomnia are extremely common in patients facing their final days or months, perhaps the rule rather than the exception (Portenoy et al., Reference Portenoy, Thaler and Kornblith1994; Vogl et al., Reference Vogl, Rosenfeld and Breitbart1999; Akechi et al., Reference Akechi, Okuyama and Sugawara2004). Treatment of these conditions is often complicated by the fact that many medications targeted at primary symptoms also cause delirium, another already prevalent and distressing symptom (Morita et al., Reference Morita, Tei and Inoue2003; Friedlander et al., Reference Friedlander, Brayman and Breitbart2004). The formulary as it existed did not specify which medications were delirium-inducing and even, paradoxically, included potentially delirium-inducing medications in the section for the treatment of delirium (Meagher, Reference Meagher2001; Samuels & Evers, Reference Samuels and Evers2002; Gaudreau & Gagnon, Reference Gaudreau and Gagnon2005). In addition, many newer groups of medications are now available to target multiple symptoms common to such patients, for example, depression and insomnia or agitation and delirium, potentially reducing polypharmacy as well as cost. The brevity of the original psychotropic medication section did not allow for such subtleties. There was an overt lack of any of the newer medications, including second generation “atypical” antipsychotics, nonbenzodiazepine hypnotics, and newer antidepressants that target multiple receptor types.
A fourth-year medical student pursuing a residency in psychiatry was serendipitously assigned to evaluate and renovate the psychotropic medication section of the hospice formulary while on a clinical hospice rotation. Together with the Director of the Psychosomatic Medicine Service and the Medical Director of the Hospice Program, a more expansive and updated section for these medications was developed.
RESULTS
A reference list long enough to include many different choices of antidepressants, antipsychotics, anxiolytics, and hypnotics was developed originally to provide more options for more difficult or more specific symptoms based on theories of neurotransmitter action (Table 1).
Table 1. Psychiatric medication formulary
aMacleod, Reference Macleod1998.
bRozans et al., Reference Rozans, Dreisbach and Lertora2002.
cBoettger and Breitbart, Reference Boettger and Breitbart2005.
dTune, Reference Tune2002.
eSkrobik et al., Reference Skrobik, Bergeron and Dumont2004.
fTune, Reference Tune2001.
gKehl, Reference Kehl2004.
Then, a secondary list was distilled from the original that was more appropriate as a quick reference for hospice nurses in the field, including only a few choices for each symptom, but diversifying options based on secondary symptoms and medical contraindications. The focus was on targeting not only the chief symptom, for example, depression, but also a secondary symptom that further categorized the primary. Often the choice of medication to treat depression is based on further characterization of such depression as agitated or as anergic. Antipsychotic choice can be driven by level of sedation desired, and treatment of insomnia may differ accordingly with propensity for delirium. As much as possible, choices are supported by evidence in the literature; when this was not possible, they are supported by a consensus of clinical experience. The shorter list was originally designed for quick reference by nurses making home visits for hospice patients. However, because it addresses common psychiatric symptoms, it is also germane to family and internal medicine physicians managing the medically ill in a hospital setting. (Table 2)
Table 2. Psychiatric medication formulary, the short list
Delirium is a common side effect of many medications; monitor patients closely for signs.
aBoettgerand Breitbart, 2005.
bTune, Reference Tune2002.
cRisperidone and haloperidol are associated with prolonged QTc and possible torsades de pointes risk (Glassman & Bigger, Reference Glassman and Bigger2001).
dSkrobik et al., Reference Skrobik, Bergeron and Dumont2004.
eOlanzapine is relatively contraindicated in patients with known diabetes (Newcomer & Haupt, Reference Newcomer and Haupt2006).
fTune, Reference Tune2001.
gMacleod, Reference Macleod1998.
hRozans et al., Reference Rozans, Dreisbach and Lertora2002.
iKehl, 2004.
“The really, really short list”
Anxiety: risperidone
Depression: mirtazapine
Insomnia: mirtazapine
Delirium: risperidone
Terminal agitation: risperidone
DISCUSSION
After a formulary is updated and improved, the next step is to increase awareness of the changes and ensure that they can be implemented in a manner useful to hospice nurses in the field, residents on the ward, or any practitioner providing preliminary care for psychosomatic symptoms. The goal is to educate care providers about new medications in the formulary, including their indications, uses, and side-effect profiles. A brief case-based seminar was developed that discussed the different medications with a focus on avoiding ones that induce delirium. Slightly different audience-appropriate versions of the in-service were designed for the hospice nurses, the psychiatry interns on the psychosomatic medicine service, and the internal medicine and family practice interns. Because the complete hospice formulary is targeted specifically at hospice caregivers, pocket cards of just the psychiatry formulary section were created and disseminated to residents for quick reference on the in-patient service. Feedback on the process was solicited in the form of follow-up surveys on changes in treatment practices among providers.
Although a hospice formulary renovation may directly benefit the hospice nurses by allowing more autonomy in the field and great efficiency in patient care, a continually evolving, easy-to-reference formulary benefits caregivers in many different specialties. Any physician or other practitioner in a primary care setting who is frequently faced with a limited symptom set outside his or her specialty would have use for such a tool. This particular approach is especially tailored to managing psychiatric symptoms, as many providers have limited training in the field and are faced with high numbers of patients with psychiatric concerns. However, this model of interdisciplinary formulary development, renovation, and education can be applied to common uncomplicated symptoms from different specialties.
